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Radiation therapy has been shown to increase the risk of lung cancer in women who have had a mastectomy to remove breast cancer. But until now, no risk has been calculated for women who have had radiation after a lumpectomy.

A new study by Columbia University Health Sciences researchers has found no risk of lung cancer from radiation therapy in women with breast cancer up to 15 years after radiation and lumpectomy. The research was published in the March 15 issue of the journal Cancer.

Dr. Alfred Neugut, professor of medicine at P&S and epidemiology at Mailman, and Dr. Lydia Zablotska, instructor in epidemiology at Mailman, calculated the risk using a SEER database that collects cancer data from nine geographic areas representing an estimated 10 percent of the U.S. population. They found no increased risk of lung cancer for either group 10 years after the radiation treatment. But between 10 and 15 years after treatment, the mastectomy group's risk doubled, while the lumpectomy group's risk remained equal to women who never had breast cancer. The mastectomy group's doubled risk also persisted beyond 15 years. Not enough data were available to calculate the risk beyond 15 years in the lumpectomy group because the procedure only became common in the mid-1980s.

Assuming a latency period of 10 years between the time of radiation therapy and the beginning of lung cancer, the researchers predict that one out of 93 women who have a mastectomy and radiation will develop lung cancer, while one out of 200 women who have a lumpectomy and radiation will develop the disease.

The researchers say that the risk from radiation after a mastectomy should be considered when weighing treatment options for young smokers. Previous studies have shown that the combination of smoking and post-mastectomy radiation raises the risk of lung cancer to more than 30 times the risk from background radiation.

—Susan Conova

In the mid-1990s, health insurance companies widely adopted the practice of requiring plan members to see a primary care doctor first before seeing a subspecialist. Early evidence indicated that such gatekeeping could decrease healthcare costs.

But it has not been clear what effect this practice has had on costs associated with children's healthcare. Now a new study led by Dr. Olveen Carrasquillo, assistant professor of medicine at P&S and of health policy and management at Mailman, finds that gatekeeping has not effectively controlled healthcare expenditures for children. The findings were published in the March issue of Pediatrics.

Dr. Carrasquillo, Dr. Susmita Pati, formerly a research fellow at P&S, and other Columbia University colleagues analyzed data from more than 3,000 children with private health insurance from a 1996 national survey of patients, healthcare providers, and hospitals conducted by the Agency for Healthcare Research and Quality. The survey compared total per capita health expenditures among gatekeeping vs. indemnity plan (fee for service) enrollees. The data on the children represent 40.4 million privately insured American children. Total expenditures were defined as payments from all sources, including third-party and out-of-pocket payments, but excluded administrative costs.

According to the study, mean total per capita annual expenditures for children in gatekeeping plans ($887) vs. indemnity plans ($881) differed by $6, less than 1 percent. After adjusting for sociodemographic and health status characteristics among children in the sample, the researchers found that mean per capita expenditures were approximately 4 percent lower for gatekeeping enrollees than for indemnity enrollees.

However, third-party payments by gatekeeping plans on behalf of their beneficiaries were $636 compared with $595 by indemnity plans. Out-of-pocket payments were, on average, $62 less for gatekeeping enrollees than for indemnity enrollees.

The study did not assess the impact of gatekeeping on quality of care, such as whether access to and coordination of care improved.

The research could have important implications for employers and health insurers who are considering reverting to the tighter gatekeeping rules of the mid-1990s. "Our analysis suggests that gatekeeping is not an effective cost containment method for children's healthcare," Dr. Carrasquillo says.

—Matthew Dougherty

Columbia University has received a five-year award from the National Institute of Diabetes and Digestive and Kidney Diseases to establish a Diabetes and Endocrinology Research Center (DERC). There are six other DERCs in the country; this is the first time in more than a decade that funding has been awarded to establish a new center. The $7.5 million award provides funding to support core research facilities that will be shared by the 55 faculty members of the Naomi Berrie Diabetes Center.

Dr. Domenico Accili, professor of medicine and the principal investigator on the grant, says the center will use the funding to build five core facilities for 1) making mouse models of obesity, diabetes, and atherosclerosis, 2) isolating pancreatic islets for transplantation and research, 3) synthesizing and purifying proteins, 4) genomics, and 5) measuring body composition and energy expenditure in humans and rodents. The fifth core facility will be developed in collaboration with the New York Obesity Research Center, another NIH-supported center, at St. Luke's-Roosevelt Hospital.

The award also allows the Berrie Center to give small grants for feasibility projects led by young investigators or established investigators in other fields. The investigators do not have to be affiliated with Columbia to receive grants. Dr. Accili says they anticipate spending money in the first year to support young faculty with promising projects in immunology and clinical investigations in children with diabetes in the Washington Heights community. In the second year, they plan to include support for research projects that study the development of fat cells.

—Susan Conova


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